Doctors and Addiction: Helping Good People with a

Bad Disease

Elinore F. McCance-Katz, M.D., Ph.D.Professor of PsychiatryUniversity of California San Francisco State Medical DirectorCalifornia Department of Alcohol and Drug Programs

Topics to be Covered

• Physician Impairment and Substance Abuse

• Alcohol and Other Mood Altering Substances:– Identification of Addiction in

Physicians– Diagnostic Criteria– Assessment and Treatment– Pharmacotherapies– Return to Practice

• Support for Impaired Physicians– Monitoring Programs: Do they work?

Learning Objectives

• To gain an understanding of the disease of addiction in physicians including – What constitutes hazardous substance

use– Warning signs– Assessment and treatment– Return to Practice

• To obtain information on how to get help at UCSF if substance use or other impairment issues are a problem

“A physician who is unable, or potentially unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skills, or excessive use or abuse of drugs including alcohol.”

How Is Impairment in Physicians Defined?

AMA “The Sick Physician”, 1973

Physician ImpairmentPhysician Impairment

Refers to situations in which health Refers to situations in which health practitioners are unable to perform their practitioners are unable to perform their professional responsibilities adequately professional responsibilities adequately because of a variety of health problems:because of a variety of health problems: Medical diseaseMedical disease Mental IllnessMental Illness Substance abuseSubstance abuse

Physician ImpairmentPhysician Impairment

Not all illness is synonymous with Not all illness is synonymous with impairment.impairment.

Impairment of work function, tends to be a Impairment of work function, tends to be a late stage of illness phenomenon rather late stage of illness phenomenon rather than an early sign.than an early sign.

By the time a physician’s practice is By the time a physician’s practice is affected usually there have been adverse affected usually there have been adverse consequences to the physician’s social consequences to the physician’s social life, family life, financial status, and even life, family life, financial status, and even physical health.physical health.

Substance Use DisordersSubstance Use Disorders

Principal cause of physician impairmentPrincipal cause of physician impairment Characteristics of addiction: Characteristics of addiction:

− Behavioral dysfunctionBehavioral dysfunction− Medical complicationsMedical complications− Co-occurring mental illnessCo-occurring mental illness

Loss of control over substance use, Loss of control over substance use, overuse, intoxication, withdrawal:overuse, intoxication, withdrawal:− Poor occupational functioning and poor clinical Poor occupational functioning and poor clinical

outcomesoutcomes− Inability to practice safelyInability to practice safely− Potential harm to patientsPotential harm to patients

Substance Use

What are hazardous use levels?

• Alcohol• >7 drinks per week for women (or > 3

drinks per occasion) and >14 for men (or > 4 drinks per occasion) (NIAAA, 2007).

• (One drink equals one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits)

Substance Use

What are hazardous use levels?• Illicit Drugs:• Marijuana• Stimulants (cocaine,

methamphetamine) MDMA• Heroin• Hallucinogens• there are no established safe

levels of use; any use could be hazardous depending on individual genetics, drug composition, environment where drug is used

Substance Use

• Prescription Medications: There are no established safe levels of recreational use or other use of prescription medications

• Physicians, like others, should have a doctor patient relationship in order to obtain prescription medications

• No self-prescribing• Don’t ask colleagues to

prescribe to you and don’t prescribe to colleagues/other staff as this does not constitute a true physician-patient relationship

Substance Use Disorders are brain diseases which are:

Treatable. Chronic and relapsive. Progressive and may be fatal if untreated.

Substance Use DisordersSubstance Use Disorders

Prevalence of DiseasePrevalence of Disease

Substance Use Disorders:Substance Use Disorders: Prevalence in physicians probably not different Prevalence in physicians probably not different

than that of the public at largethan that of the public at large ~ 10% ~ 10% (SAMHSA, 2009)(SAMHSA, 2009)

In the next few slides, we will look at In the next few slides, we will look at prevalence of substance use problems in prevalence of substance use problems in physiciansphysicians

Prevalence in Practicing Prevalence in Practicing PhysiciansPhysicians

Survey of 9600 physicians: More likely Survey of 9600 physicians: More likely than general population to use alcohol, than general population to use alcohol, opiates and benzodiazepinesopiates and benzodiazepines

2% reported alcohol abuse or dependence 2% reported alcohol abuse or dependence in last yearin last year

11%: unsupervised benzodiazepine use11%: unsupervised benzodiazepine use 18%: unsupervised use of opioids18%: unsupervised use of opioids 5 times as likely to take sedatives and 5 times as likely to take sedatives and

minor tranquilizers unsupervisedminor tranquilizers unsupervisedHughes et al. 1992Hughes et al. 1992

Prevalence in Resident Physicians

• Self-report survey data:– Among resident physicians, the use of

psychoactive substances was generally lower than it was among similar age groups in the general population

– Use of benzodiazepines was greater, with self-treatment generally being cited as the reason for such use. (Hughes et al. 1991)

Prevalence in Resident Physicians

Former anesthesiology residents: lower lifetime use of marijuana and cocaine than among other groups of residents

– Possible self-selection for drug use and specialty, but in all cases, the use of these drugs was lower among residents than among similarly aged groups in the general population.

Lutsky et al. 1991

Prevalence of Impairing Prevalence of Impairing Illnesses in Medical StudentsIllnesses in Medical Students

12% estimated to suffer depression in the first two years of school.

Women medical students have same suicide rate as male students, and 3-4 X age-matched controls.

Rates of illicit drug, prescription narcotic and alcohol abuse: 7 – 18%

Survey of 2046 students: 1.6% responded that they currently needed help for substance abuse.

Balwin et al. 1991, Center et al. 2003

Can Impairment Be Can Impairment Be Predicted?Predicted?

Physicians disciplined by their regulatory Boards were 3X as likely as to have demonstrated unprofessional behavior in medical school.

The largest number of disciplinary actions were related to the use of alcohol and drugs.

Papadikis et al. 2005

Co-Occurring Mental Illness

• Substance use disorders often co-occur with depression.

• In physicians, depression is common and has been reported to occur at a lifetime prevalence rate of 12.8% in men and 19.5% in women (Center et al,

2003, Ford et al. 1998).

Co-Occurring Mental Illness

• Suicide is a risk: Suicide prevalence (relative risk compared to the general population) for male physicians is 1.1-3.4 and 2.5-5.7 for female physicians (Frank and Dingle, 1999).

• Due to the physician’s greater knowledge of lethal drugs and access, rates of completed suicides are higher in the physician population.

What Prevents Physicians From What Prevents Physicians From Getting Help?Getting Help?

Ignorance about disease Fear of the stigma attached to

diseases such as depression and chemical dependence

Self-diagnosis and “curbside” consults Concern about confidentiality Time Constraints

What Prevents Physicians From What Prevents Physicians From Getting Help?Getting Help?

Fear of jeopardizing one’s career Culture of medical education and medicine that

rewards individuals who are self-reliant, high achievers, competitive – leads to isolation and the notion that “good doctors” have few needs

Character traits of physicians to be “self-sacrificing” at the expense of their own health and needs

Family and colleagues participating in “conspiracy of silence”

High risk conditions:

− Family history

− Access

− Domestic breakdown, stress at home

− Unusual stress at work (malpractice suit)

− Self-diagnosing and self-prescribing

− Poor self-care

Identifying the Impaired PhysicianIdentifying the Impaired Physician

It is often difficult to identify chemical It is often difficult to identify chemical dependence and substance abuse among dependence and substance abuse among our colleagues.our colleagues.

Signs are subtle and attributed to other Signs are subtle and attributed to other problems.problems.

Changes in behavior are often gradual and Changes in behavior are often gradual and overlooked on a day-to-day basis.overlooked on a day-to-day basis.

Often, the workplace is the last place to be Often, the workplace is the last place to be affected by chemical dependence.affected by chemical dependence.

Identifying the Impaired PhysicianIdentifying the Impaired Physician

What are Some of the Indicators of Substance Abuse or Addiction?

Alcohol on breath DUI Tremors Often late Mondays Missing work frequently; calling in sick Mood Swings

What are Some of the Indicators of Substance Abuse or Addiction?

• Drowsy or sleeping at work• Slurred speech on phone• Inappropriate orders• Inconsistent work performance• Deteriorating physical appearance;

weight loss• Missing medications• Unusual prescribing practices

What is Substance Abuse?

One or more in a 12 month period:Recurrent use resulting in failure

to fulfill major role obligation: work, school, home

Recurrent use in hazardous situations (e.g.: driving under the influence)

Substance-related legal problemsContinued use despite recurrent

social or interpersonal problems

What is Substance Dependence (Addiction)?

Three or more of these seven criteria in

a 12-month period:1. Tolerance (need for increasing

amounts to get expected effects)

2. Withdrawal (a group of symptoms that occurs upon the abrupt discontinuation of or a decrease in dosage of medications, recreational drugs, and/or alcohol which are usually the opposite of what effects the drug itself produces)

3. More or longer consumption than intended

What is Substance Dependence (Addiction)?

4. Cannot cut down or control use5. A great deal of time getting,

using, recovering from substance6. Activities given up or reduced7. Use despite knowledge of

health problemDiagnostic and Statistical Manual of Mental Disorders, Text Revision (

DSM IV-TR)

What If Impairment Occurs?

• Impaired physicians are removed from practice and usually enter treatment

• Intervention is undertaken to assist with getting practitioner to full medical/psychiatric assessment/treatment

• Denial is universal characteristic of disease and very difficult to overcome even in the face of overwhelming consequences.

AssessmentAssessment

Physicians generally receive multi-day assessment:− Medical evaluation− Psychiatric evaluation− Substance Abuse evaluation− Neuropsychological evaluation− Collateral information − Family Therapy evaluation

Assessment team discusses findings and determines diagnosis and treatment recommendations

Should occur at facilities that specialize in the treatment of health care professionals

Physicians, pharmacists, dentists, nurse anesthetists more likely to receive long term residential care (30-90 days)

TreatmentTreatment

TreatmentTreatment

Inpatient/Residential Treatment Components:−Detoxification−Med/Psych evaluation−Individual/Group therapy−Alcoholics Anonymous/Narcotics Anonymous

introduction−Family Therapy

Treatment Outpatient Treatment Components

(after completion of residential):−Group therapy usually weekly for 2-3

years−Continued AA/NA−Family therapy as needed−Identification of support system for

practitioner−Pharmacotherapy−Monitoring – to include urine screening

Pharmacotherapy

• Alcohol– FDA approved medications

•Naltrexone (an opioid antagonist thought to be helpful with reducing alcohol craving)

•Disulfiram (blocks alcohol metabolism with increases in acetaldehyde which cause a noxious reaction if alcohol is consumed

•Acamprosate (thought to modulate GABA and glutamate neurotransmission to help reduce craving)

Pharmacotherapy

• May be helpful; particularly for physicians who will have heavy consequences for relapse

– Physicians may be offered disulfiram over other alcohol pharmacotherapies because it can help to completely stop use which is thought to be the best option for healthcare practitioners with alcohol dependence

» Barth, 2010, Garbutt, 2009

Pharmacotherapy

• Medications for Opioid Dependence

• Methadone• Buprenorphine• Medical Boards (state regulatory

agencies) do not usually support the use of opioid agonists in addicted physicians

• Naltrexone: an opioid antagonist that blocks the positive effects of opioids; often used to treat physicians with opioid addiction

» McCance-Katz, 2005

Re-Entry to PracticeRe-Entry to Practice

Initial rehabilitation process complete Participation in continuing treatment Abstinence has been initiated and

maintained for a period of time Voluntary entry into a physician health

program that will provide monitoring services to assist with ongoing treatment and assure abstinence

Re-Entry to PracticeRe-Entry to Practice

Will be considered to re-enter practice under contract and continued monitoring with the physician health program or residency program

Contract will stipulate treatment, urine toxicology screening, work site monitoring, self-help groups

Relapse Risks

• Major opioid (e.g.: injectable drugs such as dilaudid, fentanyl) use +– Co-occurring mental disorder

• (Risk Ratio: 5.79)

– Family history of substance use disorder (Risk ratio: 2.29)

– Having all 3 risk factors • (Risk Ratio: 13.25)

Medicolegal Issues

• Legal aspects of physician impairment handled primarily at state level

• State licensing organizations can withdraw a license from a practitioner deemed to be impaired/incompetent

• Primary goal of licensing boards is to protect public from unqualified health care practitioners

Medicolegal Issues

• History of substance abuse is queried on staff applications and renewals

• Employer based drug testing increasing; positive test will be followed up with an assessment

• For physicians: National Practitioner Data Bank is repository for actions of state licensing boards, hospital medical staff actions. state medical societies and malpractice claims

• (note: voluntary entrance to substance abuse treatment is not reportable)

Is Treatment an Effective Means of Resolving Substance Abuse in Physicians?

• Physician Health Programs (treatment/monitoring/sanctions) in the U.S. are being evaluated to determine their effectiveness.Physicians with substance use disorders are often referred to such programs.

• 5-year follow up study (n=804) McLellan et al. 2008

• 19% of impaired physicians failed the monitoring program (usually by relapse early in treatment)

• 81% successfully completed treatment and returned to practice under monitoring

Is Treatment an Effective Means of Resolving Substance Abuse in Physicians?

• Alcohol or drug use was detected by urine drug screening in 19% of the remaining physicians over 5 years, 26% had multiple relapses. Relapsers were removed from practice.

• At 5 years:– 78.7% of program participants were

working as physicians– 10.8% had their licenses revoked– 3.5% retired– 3.7% died– 3.2 % unknown

How to Get Help

• Call the UCSF Faculty and Staff Assistance Program (415) 476-8279

• Location: Laurel Heights campus• Hours: M-F, 8A-5P, but 24 hour

coverage of telephone line is provided

• Same day appointments are usually available

• For more information: http://www.ucsfhr.ucsf.edu/index.php/assist/index.html

Specific information for residents and fellows about the UCSF Faculty and Staff Assistance Program:

Information includes:• charges and costs• confidentiality• scope of counseling• qualifications of the

counselors• record of interactions• reporting

http://medschool.ucsf.edu/gme/residents/RFA/tenQs/CounselingServiceFall08.pdf

How to Get Help for Others

If you have a concern about the possible impairment of a physician colleague, the UCSF Physicians Well Being Committee is a confidential resource where you can discuss this.

Call the Medical Staff Office at 885-7268 and ask to speak to the PWBC chair.

For more information: http://www.ucsfmedicalcenter.org/medstaffoffice/

References

AMA Council on Mental Health. The sick physician: Impairment by psychiatric disorders, including alcoholism and drug dependence.  JAMA 1973;223:684-687. 

Balwin DC, Hughes PH, Conard sE, Storr CL, Sheehan DV: Substance abuse among senior medical students. JAMA 265: 2074-2078, 1991.

Barth KS, Malcolm RJ. Disulfiram: an old therapeutic with new applications. CNS Neurol Disord Drug Targets 2010;9:5-12

Carrington R, Fiellin D, O’Connor PG: Hazardous and Harmful Alcohol Consumption in Primary Care Arch Inter Med. 1999;159:1681-1689.

Center C, et al. Confronting depression and suicide in physicians. A consensus statement. JAMA 289: 3161-3166, 2003.

References• Domino KB, Hornbein TF, Polissar NL, Renner G,

Johnson J, Alberti S, Hankes L: Risk factors for relapse in health care professionals with substance use disorders. JAMA 293: 1453-1460, 2005.

• Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY, Klag MJ. Depression is a risk factor for coronary artery disease in men: the precursors study. Arch Intern Med. 1998;158:1422-1426.

• Frank E, Dingle AD. Self-reported depression and suicide attempts among US women physicians. Am J Psychiatry. 1999;156:1887-1894.

• Fuller RD, Willford WO, Lee KK, Derman R: Veterans Administration cooperative study of disulfiram in the treatment of alcoholism: study design and methodological considerations. Control Clin Trials. 1984 Sep;5(3):263-73

References

Garbutt JC. The state of pharmacotherapy for the treatment of alcohol dependence. J Subst Abuse Treat 2009;36:S15-23; quiz S24-5

Hughes PH, Brandenburg N, Baldwin DC, Storr CL, Williams KM, Anthony JC, Sheehan DV: Prevalence of substance use among US physicians. JAMA 267: 2333-2339, 1992.

Hughes PH, Conard SE, Baldwin DC, Storr CL, Sheehan DV. Resident physician substance use in the United States.  JAMA 1991;265:2069-2073.

Lutsky I, Abram SE, Jacobson GR, Hopwood M, Kampine JP. Substance abuse by anesthesiology residents.  Acad Med 1991;66:164-166.

ReferencesMcCance-Katz EF, Kosten TR: Psychopharmacological

treatments. In Clinical Textbook of Addictive Disorders (third edition), S. Miller and R. Frances (eds.) Guilford Press, New York, NY, pp. 588-614, 2005.    

McLellan AT, Skipper GS: Campbell M, Dupont RL: Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008 337:a2038.

O’Malley SS, Jaffe AJ, Chang G, Schottenfeld RS, Meyer RE, Rounsaville B: Naltrexone and coping skills therapy for alcohol dependence. Arch Gen Psychiatry 49: 881-887, 1992.

Papadikis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, Veloski JJ, Hodgson CS: Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005 Dec 22;353(25):2673-82

SAMHSA, National Survey on Drug Use and Health, 2009